Tuesday Advanced Cases & Procedure Pearls

Critical Cases – Diaphragmatic Hernia!!!

by: Richard Byrne M.D.

HPI:

  • 22 yo male hx of prior GSW to L chest with retained bullet presents with chief complaint of 2 days of left sided chest and left upper quadrant abdominal pain, along with intermittent nonbilious emesis
  • No fevers, no dyspnea, normal bowel movements

Physical Exam

  • VS: T 97.3 HR 80 BP 153/70 O2 98% on RA
  • Well appearing, in no distress
  • Lungs clear bilaterally, heart sounds normal
  • Abdomen soft, +tenderness in LUQ without guarding and rebound tenderness
  • No lower extremity edema

ECG:

Chest film:

Interpretation: Apparent left sided pleural effusion, not apparent on lateral view

CT chest:

Highlighted area indicates diaphragmatic hernia with portion of the stomach in the left chest

Clinical Course

  • NGT placed to decompress stomach
  • Admitted to CT surgery
  • Had EGD to assess viability of gastric mucosa which was normal
  • Underwent open surgical repair of diphragmatic hernia with reduction of stomach into abdominal cavity

Pearls

  • Diaphragmatic hernia is a rare condition usually a sequelae of trauma
  • Conventional imaging such as CT will likely not detect an acute injury to the diphragm
  • Patients often present late after acute trauma when visceral contents herniate into the chest cavity
  • Exam may demonstrate acute respiratory distress and bowel sounds on pulmonary auscultation
  • Patients may be in frank shock from gastric/intestinal ischemia
  • Treatment is surgical, usually cardiothoracic

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